Ending the doctor–patient relationship

Withdrawing your source of care to a patient should be done for the correct reasons, and in the correct fashion. Badly handled, the situation could cause you to attract complaints, says MPS Medical Adviser Dr Andrew Stacey

The doctor–patient relationship is the cornerstone of clinical care. It is essential that the relationship is based on openness, trust and good communication in order to enable the doctor to work in partnership with the patient to address their needs.

Patients usually select a doctor with whom they feel comfortable. Thus doctor–patient relationships more commonly end because the patient is moving area, or wishes to see another doctor. There will, however, be situations where the relationship breaks down and the doctor wishes to end the relationship. This is a conclusion that needs to be reached objectively and dispassionately if it is not to potentially harm both parties.

A decision to end the relationship should not be made lightly. The breakdown should be to the extent that the doctor feels that to continue to provide care is not in the patient’s best interests. It is strongly recommended that before doctors make this decision, they should have explored all reasonable alternatives. The doctor should be able to justify the decision to discontinue the relationship, and the actions taken by the doctor will be instrumental in rebutting any subsequent complaint.

The official guidance

In an article for NZ Doctor in June 2005, Ron Paterson, the then Health and Disability Commissioner, said: “Clearly, terminating care is not an appropriate method of handling a complaint. If faced with a difficult decision to end a doctor–patient relationship, the process must be clearly communicated, fair, and conducted in accordance with professional and legal obligations. Maintaining a relationship in the face of a complaint can be a challenge – but it can also be an opportunity to resolve misunderstandings and improve communication and care for the future. Calling it quits should be an option of last resort.”

The NZMA Code of Ethics states: “In any situation which is not an emergency, doctors may withdraw from or decline to provide care as long as an alternative source of care is available and that the appropriate avenue for securing this is known to the patient. Where a doctor does withdraw care from a patient, reasonable notice should be given and an orderly transfer of care facilitated.”

The MCNZ, in its statement Ending a doctor–patient relationship, sets out the process for discontinuation of care and notes the process must be clear so the patient no longer has any expectations of ongoing care:

The doctor should tell the patient that the relationship has ended and explain why this decision has been made.

A note of this decision should be made in the patient’s records.

The doctor should refer the patient to another doctor of the patient’s choice (or in the case of a specialist, back to the patient’s general practitioner).

The referral letter and accompanying information should be clinical, relevant and objective.

The patient should be assisted to locate an alternative doctor, and/or given sufficient notice so that they can find another doctor.

Conclusion

When a doctor decides to end the doctor–patient relationship, it is not uncommonly perceived by the patient as a punitive or rejecting act and is a situation in which there is a high risk of complaint and so must be managed carefully. MPS advises members to seek advice at an early stage where ending a difficult relationship is contemplated.

Case study

Although at times patient expressions of dissatisfaction, or making a complaint, may be interpreted as a breakdown in the relationship, a Health and Disability Commissioner (HDC) case from 2008 highlights the pitfalls of treating a complaint as evidence of an irretrievable breakdown in the relationship:

Mrs A and her family were patients of Dr X at a rural medical centre owned by Dr Y who employed Dr X and others.

In mid-2008 Mrs A brought in her daughter with a sore throat. The child was seen by one of the other doctors, and diagnosed with a viral infection. A throat swab was taken. When the child’s condition deteriorated later that day Mrs A took her to another medical centre. Tonsillitis was diagnosed and antibiotics prescribed.

Later the same day, Mrs A wrote to Dr Y, complaining that the other medical centre had informed her that a throat swab was unreliable in a child of that age. She recounted a previous incident of dissatisfaction with care provided and stated she would refuse to see that doctor in future. She requested a refund of the fee. The practice nurse telephoned Mrs A but was unsuccessful in resolving the complaint.

Twelve days later Dr Y responded, stating he had reviewed both episodes of care and found they were “completely appropriate”. He refunded the fee and removed the family from the patient register, concluding the practice could not meet Mrs A’s expectations.

She stated she would not have complained had she known her family would have been disenrolled

Mrs A wrote to state she was very disappointed with his response and asserted her right to express dissatisfaction with the consultations.

Two months later, after no response, she complained to the HDC, noting the difficulties in finding alternative medical care without excessive travel. She stated she would not have complained had she known her family would have been disenrolled.

The PHO, at the Commissioner’s request, tried to broker a solution, but Dr Y felt the therapeutic relationship was irreparably damaged. The Commissioner then rang Dr Y, explaining that he believed Dr Y had breached Mrs A’s rights, by denying her a right to complain, and failing to comply with relevant standards (the PHO’s disenrollment rules, and the NZMA Code of Ethics).

After reflection, Dr Y phoned the Commissioner, stating he was willing to reinstate enrolment for a six-month trial, though he feared fresh complaints. Thus, doctors should be cautious about ending a relationship where there has been, or is a possibility of, a complaint. In these circumstances it is strongly advised that doctors phone MPS for advice.

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